Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Dominican University, River Forest, IL, USA.
J Gen Intern Med. 2021 Oct;36(10):3071-3079. doi: 10.1007/s11606-021-06788-4. Epub 2021 May 13.
At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context.
We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain.
Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants.
This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success.
与此同时，联邦政策制定者实施了限制移民的政策，美国各地的医疗保健系统也在发展，并实施了旨在解决移民社区面临的移民相关压力源的干预措施。然而，人们对影响其实施成功的背景决定因素知之甚少。本研究使用实施研究综合框架（CFIR），确定了在医疗保健背景下实施旨在减轻移民相关压力源的干预措施的有利和不利因素。
我们采用定性研究设计，在五个移民人口最多的州（加利福尼亚州、德克萨斯州、纽约州、佛罗里达州和伊利诺伊州）的 25 家医疗保健机构中，对参与干预措施实施的利益相关者进行了 38 次半结构化访谈。访谈于 2018 年 5 月至 8 月进行。使用恒比分析确定障碍和促进因素主题。此后，采用演绎编码根据 CFIR 域对主题进行分类。
实施障碍包括对法律复杂性的认知以及对采用此类系统策略的挑战。促进因素包括将移民健康问题提上国家政策议程的全国性政策气候，从而为推动体制变革提供了动力；医疗保健人员之间的沟通；与移民权利和服务组织的现有社区伙伴关系；以及以实现健康公平为中心的共同使命感。与移民相关的政策（例如，执法移民法的地方执法机构）的地方差异以及当地移民社区的异质性也影响了实施。拥护者和非正式领导者是机构努力的重要组成部分，但不足以保证可持续性。采取行动的紧迫性超过了评估考虑因素，所有干预措施都处于初始实施阶段。需要对这些干预措施进行进一步迭代和评估，以确定最佳实践和实施决定因素。
这是第一项系统研究，描述了医疗保健系统中与移民相关的干预措施的实施决定因素。确定这些决定因素为其他医疗保健组织提供了指导，以有效地制定战略并确保实施成功。
